Monday, December 17, 2007

When newFNP returned to work and asked Dr. Dual-Ivy-League-Degrees if Cocoa had returned to clinic for her syphilis treatment, she stated that she had and proceeded to recount a story that put Cocoa Brown into a special kind of crazy league. NewFNP is not talking about the kind of crazy that causes you to feel that it's appropriate for your BFF to check out your herpetic labia or the kind of crazy that remarks con gusto about vaginal odors. No, this is a new kind of crazy.

One might call this kind of crazy "felonious."

Apparently, when CB learned of her multiple STI diagnosis, she confronted her new partner, a wise and responsible move all in all. That is where wisdom and responsibility end and crazy as fuck enters. CB's partner, upon learning of her HSV infection, informed her that herpes was not likely to be the only infection that she had and that she had better check in with her doctor.

At this point, Cocoa Brown understandably lost her shit. Who wouldn't? One would assume that words such as "motherfucking asshole shitlicker" and "son of a bitch piece of shit no good dog-humper" would be employed, that voices would assume a fever pitch, that the sensation of imminent explosion resulting from extreme anger would be palpable.

One would not expect, however, that Cocoa Brown would attack her disrespectful partner with a 2x4 that had exposed nails with such vigor that he was hospitalized, but that is in fact just what happened. According to newFNP's colleague, she seemed not at all disturbed by this.

CB went on to explain to Dr. Dual-Ivy-League-Degrees that she had previously been incarcerated for prostitution and "other things." What could those be, newFNP wonders? Aggravated assault? Assault with a deadly weapon? Jaywalking? Furthermore, Cocoa is apparently treated for mental illness.

Just a hunch, here, but newFNP thinks that she might need a med adjustment.

Thursday, December 13, 2007

NewFNP's readers are already familiar with our good friend Downtown Cocoa Brown. As it turns out, she not only had a culture confirmed herpes infection, but also had a bonus STD: syphilis!

Hooray!

NewFNP, upon receiving the result from her lab and seeing the reactive FTA with a 1:8 titer, called her local public health department. She asked the helpful STD man if he had any record of having ever treated Ms. Cocoa Brown for said treponemal infection. He had not. NewFNP then proceeded to call Cocoa and ask if she had ever been diagnosed or treated for syphilis. She had not. NewFNP strongly encouraged her to return to the clinic A.S.A.P. in order to glean a better syphilis-related history and to start her some some sweet Pen G. Oh, and in the meantime, do public health a favor and keep those sweet legs tightly closed, would ya hon?

This was Tuesday. She swore she would be in Wednesday at 8:30 AM. NewFNP even requested an overbook. Therefore, one can imagine the importance newFNP placed on this visit. Around 9:30 on Wednesday, newFNP received a phone call from Cocoa's friend, the vagina voyeur, noting that they were a little on the late side in coming in for the syphilis appointment but that, not to worry, they would be there.

The dynamic duo never showed.

Again, newFNP feels compelled to point out the differences between her experience as a patient and that of her patients'. If newFNP has a blemish, she is powerless to not treat it. And she is talking about a micro-papule that she and only she can appreciate while her otherwise dewy and glowing skin is illuminated in the magnifying mirror. Intralesionalkenalog STAT! If newFNP'svag* doctor told her that she had motherfucking syphilis, she would be destroying herself with penicillin!

NewFNP received a call today from the friend. The reason that Cocoa Brown had not returned to the clinic is that her friend's foot hurt "real bad." Ever heard of a bus? Taxi? Tricycle? Walking?

They swear that they will be there tomorrow. NewFNP, alas, will not. Her new work buddy, Dr. Dual-Ivy-League-Degrees, will. As sad as the case may be, newFNP knows that Dr. Dual-Ivy-League-Degrees will have quite a time with these two.

Tuesday, December 11, 2007

NewFNP found herself in something of a clinical pickle today. She has a patient for whom she has been caring for his diabetes for quite some time now. However, he had not been to clinic in over a year when newFNP happened to run into him last week as he was exiting his dental appointment.

"How are you?" he asked, in Spanish of course, as he gave newFNP a warm hug - a practice of several of newFNP's patients. "How was India? Are you married?"

"India was great," newFNP replied. "And I'm single."

He proceeded to tell newFNP how he was in the midst of a divorce and that he would take all of newFNP's worries away by making her his second wife. Nice gesture, but newFNP will decline with a wave of the hand and a shake of the head.

Fast forward two weeks and here this gentleman is in newFNP's exam room for diabetes care. He told newFNP that he and his wife were considering divorcing because he, at age 45, wants a child and she, at age 50, is unable to provide him with one. NewFNP noted to herself his mid-life crisis, practiced supportive listening and attempted to steer him back toward the safer ground of DM2.

He, however, was not to be swayed. We chatted a little more about decisions, how one never knows what life will hand them, blah blah blah. What is this, talk therapy? After some more chatting and a sprinkle of dietary education thrown in for good measure, newFNP stood up from her rolly stool and declared that it was time to go to the lab.

At this point her patient stood up, went to embrace her and kissed her. On the lips. No tongue, but still. He then invited newFNP to "have babies with him." He was joking, of course. Right? NewFNP blushed eight shades of red and told him to knock it off.

What a bummer. NewFNP used to look forward to her visits with this intelligent and, today notwithstanding, thoughtful patient. Now she needs to wear a teeth guard and perhaps some Mormon underwear before she enters the room.

Friday, December 07, 2007

When purchasing her new car earlier this year, newFNP felt confident that it would not be tampered with when she parked it in her clinic's ghetto-esque area. Why, you ask? It is because, time and time again, newFNP noted that all around her were big trucks with flashy 16-inch rims, SUVs with the same, minivans with those spine chilling stick-figure family stickers, or piece of shit junkers with piece of shit spinning rims. NewFNP bought a hybrid, a very hybridy-looking hybrid. They are not so common or coveted in newFNP's hood.

NewFNP loves cars. In her dream world, she would have her sweet hybrid and she would have a sweet Audi S6 all-wheel drive wagon for snowboarding with George Clooney. But she would not, under any circumstances, buy a big truck, fashion a skull whose eyes glowed red when she stepped on the brakes to the trailer hitch and hang from its truck underbelly a huge pair of swinging rubber bull testes.

Yet newFNP has seen this accessory more than she would have liked to. For the record, she would have liked to have seen it exactly once, just for shits and giggles, but to have seen it repeatedly feels somewhat abusive. Does newFNP really need to be hypnotized by faux balls as she leaves work?

Who hangs these balls from their truck? Do they have female partners who deign to be seen in such a masculinely adorned vehicle? Do they feel appropriately shamed when they go to the bull-ball store and weigh the decision regarding color? Do they cup their purchase in their palms and feel pride? And - really - who chooses blue?

NewFNP knows the message that these chaps are trying to put out there. They are saying, "Do not fuck with me. Smoke comes from my nostrils when I am incensed. Furthermore, my testicles are laden with semen and my semen, if you must know and - trust me - you must, is the stuff of legend. In fact, I am quite certain that there exists a tome entitled 'La Leyendade mi Semen.' My erections are formidable."

The message received by newFNP is more like this: I am compensating for my small, poorly functioning penis, I do not know where the clitoris is, and I drink too much.

Thursday, December 06, 2007

NewFNP has rarely, if ever, found herself in the position of requiring - let alone desiring - a friend's presence while at the doctor. Truth be told, she would rather keep that part of her life private. Especially as it relates to her lady business. Good news? Great! Bad news? Private!

However, if newFNP's patients want to drag their sisters/friends/cousins to their appointments, who is newFNP to deny them? Of course, newFNP asks family members to exit the room during sensitive histories or exams, but respects it if her patients want to use the buddy system.

This morning, when newFNP read the chief complaint of "boil on her vagina," she felt a little glee at the thought of incising and draining what she assumed to be an abscess. It's been a long time since newFNP performed any mini-surgery and, frankly, she's been missing it.

Alas, it was not to be.

NewFNP received permission to make this a group visit and proceeded to ask her patient who, by the way, had a BMI of 41, how she could be of help. Her friend, whose BMI was easily 50-plus, piped up with, "She got a boil on her cocoa brown!"

NewFNP elicited the pertinent history and got the patient into the lithotomy position - no easy task - and began to survey the region when her friend came around to get a lay of the land as well. NewFNP quickly maneuvered the makeshift drape in order to cover her patient.

"Whoa, whoa, whoa," newFNP said. "Is it okay with you if she looks?" NewFNP's patient, astoundingly, gave her the go ahead and her friend jumped on in.

Again, newFNP would prefer that all of her friends would just stay the hell out of her own cocoa brown. Permission to view the pelvic exam denied!

This lady's cocoa brown wasn't exactly rocking the cocoa puff, per se, but more of the cocoa herpes. When newFNP asked her if she had a new partner, she answered in the affirmative. After determining that this was a male partner, she asked if he was a good guy. Her friend emphatically answered that he was, in fact, not. To which, newFNP's patient informed the room that she would no longer be "fucking with him."

Good then. NewFNP provided some safer sex counseling, offered further STI screening, and bid these two fine ladies adieu.

Wednesday, December 05, 2007

For instance, she knows that she should not wear black trousers with brown shoes, even if the shoes are Sigerson Morrison and cute as hell. She knows that grown men should not wear bikini underpants. In fact, if she were pressed, newFNP would assert that no men - regardless of age - should wear bikini underpants. Not even George Clooney. Because if there is anything that could render an otherwise ridiculously handsome and obviously virile man pathetically unattractive, it's bikini underpants.

NewFNP also knows that when one auscultates a carotid artery, it should not sound like there is a frigging Harley Davidson Chopper racing through at breakneck speed. And it sure as shit should not be happening on both sides. No, the finding of bilateral rumbling carotid bruits is undesirable. In concert with a fasting glucose of 392 and a BP of 204/90, it makes newFNP's eyes glaze over and forces her to consider a career as a nail salon girl. In an upscale salon, of course.

If newFNP were to adopt a "half-full" approach, she would be gratified to observe how well one can look and for how long one can push on while one's blood supply to the head is compromised.

What's that, you say? You're dizzy? No shit.

The reason that newFNP's is able to observe just how long a person can survive with said pathophysiology is that this patient, like so many others, is uninsured. Sure, when she went to the ED after passing out in her chair for no apparent reason and newFNP called the attending physician to give a little carotid bruit heads up, one would think that this patient would have exited the hospital with, oh, let's say having had a duplex ultrasonography and an MRA. One would be wrong.

NewFNP sent off the referrals today. Frankly, until this lady gets health insurance, newFNP is not hopeful that her condition, which clearly warrants an urgent evaluation, will be so.

Did newFNP mention that this patient is 57 years old? Not exactly a spry fifty-seven.

Sunday, December 02, 2007

NewFNP recently had a conversation with a good pal from grad school, BostonCNM (not to be confused with although currently and temporarily co-habitating with BostonFNP). BostonCNM has recently changed practice sites from a cushy suburban practice with an educated clientele committed to a midwife assisted birth to a ridiculously busy community health center in a wrong-side-of-the-tracks area of Boston.

There is something deeply validating about sharing the experience of working in a completely fucking disorganized setting, yet loving the work that you do -- and bitching about it with one of your BFFs.

It started newFNP thinking about how one might truly know that they are working in urban community health. What are the requisite community health bona fides? NewFNP will share them with you.

1) In general, your patients will not speak your primary language. Their language might have no written form or may consist of clicks, thus making them impenetrable to an otherwise educated and teachable person. You may perhaps speak the language, but that would mean that you or your parents had acumen which started you off on the Spanish language path at an early age. NewFNP's mom had that insight. Sadly, newFNP was both intransigent and snobby and insisted, at the age of eleven, that she would speak French. While this proved quite helpful during her Tahitian vacation at the age of seventeen, it has proven itself much less so in the years since.

2) You will run out of crucial supplies. These may include but are by absolutely no means limited to: specula; lead testing strips; table paper; otic thermometer probe covers; patient drapes/gowns; charts; and medications. Furthermore, you will discover that these supplies are missing at inopportune moments, such as when your patient is in the lithotomy position, covered with paper towels and with two serving spoons fashioned into a speculum by the ingenious placement of folded cardboard and a rubber band in lieu of the real deal.

3) You will care for patients who have absolutely no idea how to care for their health. You will feel astounded at this. This feeling will not go away.

4) Your patient no-show rate will be in the 50-70th percentile. Therefore, your front desk staff will bring in tons of walk-ins. And then, one day, your no-show rate will be 10% but they will still let in the walk-ins. On those days, you will be fucked.

5) You will work with people who frustrate you and who could, at times when one is feeling less than generous, be considered incompetent. NewFNP has noted this before, but believes that because it is so intrinsically linked to community health practice, it is worth noting anew. See Office Staff Rant for a more thorough investigation of this phenomenon.

6) You and your co-workers will have more than one job. Medical assistants double as referral coordinators. Admin assistants place the orders. Providers do everything. NewFNP makes copies, fills out a trillion forms, writes letters and fields phone calls from senior management asking about this or that. This does not lead to efficiency, nor does it lead to satisfactorily completed tasks. Moreover, it may contribute to job dissatisfaction.

7) You will have crazy stories to share with your pals who work in law or fashion or business. You will frequently hear phrases such as "No fucking way" or "What the fuck?!" or "Jesus, how long do you have to stay there?" when you recount these stories.

8) In the end, goddammit, the goods will outweigh the bads and you will feel good about your work at the end of the day. But not so much in the morning when you see the line snaked around the block as you walk into another day of 10-15 minute appointments.

This blog is for new NPs or NP students who want some real 411 on the life of a new practitioner. A new practitioner in a busy, understaffed, urban community health clinic in a major metropolitan area. Oh, and newFNP swears while writing and, sometimes, while working although she tries to keep those swears to herself. Consider yourself warned.